Psychosocial Best Practices for Working with Clients with Dementia | Occupational Therapy Practice

Introduction

Clients with dementia often live at home for as long as they are able until later stages of the disease. Before dementia was understood in earlier history, clients were labeled with terms such as “confused” and “disoriented”. Our recent understanding of dementia has promoted efforts in considering and addressing the psychosocial components of the client. Occupational therapists can use a psychosocial approach and best practice theories and programs to promote and optimize function for clients and their families.

Impact on function

Physical and Cognitive

Terms:

  • Aphasia – impairs the client’s ability to communicate with speech and language.
  • Apraxia – impairs the client’s ability to perform purposeful movements.
  • Agnosia – impairs the client’s visual, auditory, and tactile functions.
  • Executive function – impairs the clients’ ability to think abstractly and to plan complex tasks in their environment.

Decreasing Function

Patients with later stages of dementia often present with multimorbidity.[1]Melis, R. J., Marengoni, A., Rizzuto, D., Teerenstra, S., Kivipelto, M., Angleman, S. B., & Fratiglioni, L. (2013). The influence of multimorbidity on clinical progression of dementia in a … Reference List The order of function that typically deteriorates (but not always) is:

  1. Clients may first demonstrate deterioration in work and volunteering as these often require higher executive function and complex demands mentioned earlier.
  2. Leisure may decrease next due to a demand on higher cognitive skills and social participation skills.
  3. IADLS such as shopping, home management, and meal preparation may be next to deteriorate as clients demonstrate cognitive difficulties such as memory.[2]Fieo, R., Zahodne, L., Tang, M. X., Manly, J. J., Cohen, R., & Stern, Y. (2018). The historical progression from ADL scrutiny to IADL to advanced ADL: assessing functional status in the earliest … Reference List
  4. ADLs are often the last to deteriorate and vary depending on the specific activity of dressing, bathing, and grooming.
  5. Sleep-wake cycles are typically disturbed in later-stage dementia.[3]Cipriani, G., Lucetti, C., Danti, S., & Nuti, A. (2015). Sleep disturbances and dementia. Psychogeriatrics, 15(1), 65-74.
  6. Functional mobility may be impacted in late-stage dementia requiring 24 hour care.

Stages and Goals

All stages – from no cognitive decline at stage 1, all the way to stage 7 of very severe cognitive decline, warrant psychosocial consideration and intervention. Often, in the middle stages of moderate decline is when psychosocial interventions are tailored and focused on family and caregivers to set goals with the client.

Goals that have been identified for dementia can be categorized across five domains: medical care, physical quality of life, social and emotional quality of life, access to healthcare services and supports, and caregiver support. For participants with early-stage dementia, engagement in meaningful activities such as work and family functions have been identified. Caregiver goals that have been identified include safety and managing caregiver stress. Culturally, when working with non-english speaking families, there should be an emphasis on improving community education about dementia.[4]Jennings, L. A., Palimaru, A., Corona, M. G., Cagigas, X. E., Ramirez, K. D., Zhao, T., … & Reuben, D. B. (2017). Patient and caregiver goals for dementia care. Quality of Life Research, … Reference List

Popular Approaches

Different approaches have a different emphasis on the strengths and barriers and therefore may have very different goals for the same client.

  • Psychodynamic
  • Reminiscence/Life review
  • Support groups
  • Reality orientation
  • Memory training
  • Behavioral

Psychodynamic, reminiscence and life review therapy, and support groups all deal to some extent with the individual’s subjective experience of the disease. Behavioral and cognitive therapies for depression, by definition, target subjective distress. One presumed source of distress, memory, is addressed by reality orientation and memory training.[5]Brodaty, H., Green, A., & Koschera, A. (2003). Meta‐analysis of psychosocial interventions for caregivers of people with dementia. Journal of the American Geriatrics Society, 51(5), 657-664.

Psychosocial OT Best Practices

The Allen Cognitive Disabilities Model can be used for clients with dementia. Strengths of the ACDM include measuring strengths and remaining abilities. It facilitates function and safety instead of restoring function (which is likely possible). Tasks are modified to promote function such as via the environment. Successful strategies are taught directly to caregivers via teaching that is family-centered. Activities are promoted that are within the client’s ability to bring a sense of meaning instead of distressing the patient.

A Tailored Activity Program can be used to address behavioral symptoms of dementia such as resistance to care, vocalizations, or physical aggression. This maximizes the client’s quality of life while maintaining their safety in their environment. TAP is a home-based occupational therapy intervention that identifies the interests and capabilities of clients with dementia to their individual profile. Caregivers are then trained to use such activities as part of their daily routines. Research for TAP has shown improvements compared to wait-list control groups. The official TAP involves eight sessions that include three general phases:

  • Phase 1: Assessment of caregiver, dementia patient, and environment
  • Phase 2: Introduction of activity, communication, task breakdown, and environmental simplification techniques
  • Phase 3: Generalize strategies

Within TAP, the Dementia Rating Scale, a 36-item standardized assessment can be used to assess for attention, initiation/perseveration, construction, conceptualization, and memory. A large part of the program is activity prescription and caregiver training. Overall, the benefits of TAP include decreased negative behaviors and reduced caregiver burden.[6]Laura N. Gitlin, PhD, Laraine Winter, PhD, Tracey Vause Earland, MS, OTR/L, E. Adel Herge, MS, OTR/L, Nancy L. Chernett, MPH, Catherine V. Piersol, MS, OTR/L, Janice P. Burke, PhD, OTR/L, FAOTA, The … Reference List

References

References
1 Melis, R. J., Marengoni, A., Rizzuto, D., Teerenstra, S., Kivipelto, M., Angleman, S. B., & Fratiglioni, L. (2013). The influence of multimorbidity on clinical progression of dementia in a population-based cohort. PloS one, 8(12), e84014.
2 Fieo, R., Zahodne, L., Tang, M. X., Manly, J. J., Cohen, R., & Stern, Y. (2018). The historical progression from ADL scrutiny to IADL to advanced ADL: assessing functional status in the earliest stages of dementia. The Journals of Gerontology: Series A, 73(12), 1695-1700.
3 Cipriani, G., Lucetti, C., Danti, S., & Nuti, A. (2015). Sleep disturbances and dementia. Psychogeriatrics, 15(1), 65-74.
4 Jennings, L. A., Palimaru, A., Corona, M. G., Cagigas, X. E., Ramirez, K. D., Zhao, T., … & Reuben, D. B. (2017). Patient and caregiver goals for dementia care. Quality of Life Research, 26(3), 685-693.
5 Brodaty, H., Green, A., & Koschera, A. (2003). Meta‐analysis of psychosocial interventions for caregivers of people with dementia. Journal of the American Geriatrics Society, 51(5), 657-664.
6 Laura N. Gitlin, PhD, Laraine Winter, PhD, Tracey Vause Earland, MS, OTR/L, E. Adel Herge, MS, OTR/L, Nancy L. Chernett, MPH, Catherine V. Piersol, MS, OTR/L, Janice P. Burke, PhD, OTR/L, FAOTA, The Tailored Activity Program to Reduce Behavioral Symptoms in Individuals With Dementia: Feasibility, Acceptability, and Replication Potential, The Gerontologist, Volume 49, Issue 3, June 2009, Pages 428–439, https://doi.org/10.1093/geront/gnp087
Jeff is a licensed occupational therapist and lead content creator for OT Dude. He covers all things occupational therapy as well as other topics including healthcare, wellness, mental health, technology, science, sociology, and philosophy. Buy me a Coffee on Venmo.